Overview
Gonorrhoea is a sexually transmitted infection (STI) caused by the Gram-negative diplococcus Neisseria gonorrhoeae, affecting the mucous membranes, including the genitourinary tract. It can also affect the conjunctiva and pharynx.
It is spread by direct inoculation from one mucous membrane to another.
Associations
- Ascending infection – infections can spread up the genitourinary tract
- In women, this can cause pelvic inflammatory disease (PID) and Fitz-Hugh-Curtis syndrome
- In men, this can cause prostatitis and epididymo-orchitis
- Eye infections – often due to autoinoculation
- Septic arthritis – due to haematogenous spread
- Neonatal infection – due to spread from the maternal genitourinary tract. This may cause ophthalmia neonatorum
Epidemiology
- Gonorrhoea is the second most common STI in the UK and globally after Chlamydia
- Diagnoses of STIs are highest in people aged 15-24 years old in the UK
- Gonorrhoea infection is associated with deprivation, particularly among young heterosexual people in urban areas
Risk Factors
- <25 years old
- New sexual partner
- Multiple sexual partners
- Lack of barrier contraception use
- Sexual abuse
Presentation
Overview
Features of gonorrhoea include:
- In women:
- Purulent discharge is the most common feature (~50%)
- Lower abdominal pain (~25%)
- Features of pelvic inflammatory disease
- In men:
- Mucopurulent/purulent urethral discharge (~80%)
- Dysuria (~50%)
- Rectal infection is often asymptomatic but features can include anal discomfort/pain, discharge, and tenesmus
- Pharyngeal infection may cause sore throat
- Disseminated gonococcal infection may occur in some cases, this is discussed below under Complications.
Investigations
Referral and diagnosis
All people with suspected gonorrhoea should be referred to a genitourinary medicine clinic for diagnosis. If this is not possible, testing can be done in primary care.
Diagnosis is made using either of the following on a vulvovaginal swab in women or a first-catch urine sample in men:
- Nucleic acid amplification test (NAAT)
- Culture – identifies Gram-negative intracellular diplococci
Management
Overview
- 1st-line: single dose of IM ceftriaxone or treat according to sensitivity
- If inappropriate/contraindicated: single dose oral cefixime + single dose oral azithromycin
Complications
Pelvic inflammatory disease (PID) – can happen in up to 1/3 of people with gonorrhoea and may lead to chronic pelvic pain, infertility, or ectopic pregnancy.
Perihepatitis (Fitz-Hugh-Curtis syndrome) – gonorrhoea can ascend from the vagina into the endometrium, into the Fallopian tubes and the peritoneal cavity, causing inflammation of the hepatic capsule, resulting in right upper quadrant pain.
Obstetric complications – including spontaneous abortion, premature labour, premature rupture of the membranes, and perinatal mortality. And ophthalmia neonatorum.
Disseminated gonococcal disease – a serious complication that may affect up to 3% of people due to bacteraemia and haematogenous spreading causing septic arthritis, tenosynovitis, migratory polyarthritis, and petechial/pustular skin lesions. Rarely, it can cause meningitis or
Complications in men – these include epididymo-orchitis/prostatitis due to ascending inflammation, infertility due to epididymal inflammation, and urethral strictures.
